Use of B-Type Natriuretic Peptide (BNP) and N-Terminal proBNP (NT-proBNP) as Diagnostic Tests in Adults With Suspected Heart Failure

Ontario Health
Record ID 32018000752
Authors' objectives: This health technology assessment evaluates the diagnostic accuracy, clinical impact, and cost-effectiveness of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) for adults with suspected heart failure. It also evaluates the budget impact of publicly funding BNP and NT-proBNP tests and the experiences, preferences, and values of people with suspected heart failure.
Authors' results and conclusions: Results We included eight systematic reviews in the clinical evidence review. B-type natriuretic peptides and NT-proBNP had a high pooled sensitivity (80% to 94% and 86% to 96%, respectively; strength of evidence: high) and a low pooled negative likelihood ratio (0.08–0.30 and 0.09–0.23, respectively; strength of evidence: not reported) within varying thresholds or cut points and settings, as reported in seven systematic reviews. In one systematic review, when BNP or NT-proBNP was used in the diagnosis of heart failure in the emergency department (ED), there was a decrease in the mean length of hospital stay (−1.22 days; confidence interval [CI] −2.31 to −0.14; Grading of Recommendations Assessment, Development, and Evaluation [GRADE] Working Group criteria: Moderate). B-type natriuretic peptide testing did not reduce hospital admission rates (odds ratio [OR]: 0.82; CI: 0.67–1.01; GRADE: Moderate), 30-day hospital readmission rates (OR: 0.88; CI: 0.64–1,20; GRADE: Moderate), or hospital mortality rates (OR: 0.96; CI: 0.65–1.41; GRADE: Moderate). No systematic review was identified that addressed the impact on clinical outcomes of BNP use in the community setting. Our economic literature review found a total of 12 studies evaluating the cost-effectiveness of BNP or NT-proBNP testing in patients with suspected heart failure. The studies suggested that BNP or NT-proBNP tests, when used in addition to standard clinical investigations, were either dominant (less costly and more effective) or cost-effective across different countries (including Canada) and settings. Two economic evaluations conducted by NICE were considered applicable to our research question and of high methodological quality. Based on the transferred results from the two NICE economic evaluations, we concluded that BNP and NT-proBNP were highly likely to be cost-effective in Ontario in the ED setting, and NT-proBNP was highly likely to be cost-effective in the community care setting. Our budget impact analysis estimated that over the next 5 years, publicly funding BNP and NT-proBNP tests would result in an additional cost of $38 million in the ED (at a cost of $75 per test) and a cost savings of $20 million in community care (at a cost of $28 per test). We received strong support from interview participants about BNP or NT-proBNP diagnostic testing. The main reason was the perceived potential benefit of receiving a speedier diagnosis. The overall process, from diagnosis to treatment, is a substantial emotional burden for patients and caregivers, and for those living further away from secondary or tertiary care settings. An earlier diagnosis could allow patients to receive treatment at a hospital better equipped to manage their potentially fatal symptoms and conditions. Conclusions B-type natriuretic peptide and NT-proBNP tests have high sensitivity and low negative likelihood ratio, suggesting that concentrations of either natriuretic peptides within the appropriate cut points can rule out the presence of heart failure with a high degree of confidence. Additionally, BNP or NT-proBNP testing along with usual care in an ED setting likely can reduce the length of hospital stay by at least 1 day but likely results in little to no difference in hospital mortality, 30-day readmission, or admission rates to hospital. Based on the published economic literature, we expected BNP or NT-proBNP tests used in addition to standard clinical investigations to be cost-effective as a rule-out test in patients with suspected heart failure in Ontario. If BNP and NT-proBNP tests are publicly funded in Ontario, we estimated that there would be additional costs in the ED setting (due to increased detection of heart failure) and savings in community care (due to reduced referrals to echocardiography and cardiologists). People we interviewed gave BNP and NT-proBNP testing strong support, citing the perceived benefits of quicker, more accurate diagnoses that could reduce misdiagnoses, stress, and the burden on patients and caregivers.
Authors' recommendations: Ontario Health, based on guidance from the Ontario Health Technology Advisory Committee, recommends publicly funding natriuretic peptide (BNP or NT-proBNP) testing for the diagnosis of people with suspected heart failure in the community and emergency department settings
Authors' methods: We performed a literature search of previously published systematic reviews of the clinical evidence. We conducted an overview of reviews and included only reviews with a low risk of bias as assessed using the Risk of Bias in Systematic Reviews tool (ROBIS). We excluded any reviews where we found 100% overlap of included primary studies and selected systematic reviews or health technology assessments published after 2006 for inclusion. We performed an economic literature review of BNP and NT-proBNP testing in people with suspected heart failure. Medical and health economic databases were searched from database inception until July 25, 2019. Next, we assessed the cost-effectiveness of BNP and NT-proBNP based on the published economic literature. We transferred the cost-effectiveness results of two applicable, recent economic evaluations from the National Institute for Health and Care Excellence (NICE) to the Ontario setting in lieu of conducting de novo primary economic evaluations. We also estimated the budget impact of publicly funding BNP and NT-proBNP tests in people with suspected heart failure in Ontario over the next 5 years. To contextualize the potential value of BNP and NT-proBNP testing, we spoke with people with suspected heart failure.
Project Status: Completed
Year Published: 2021
Requestor: Ontario Health Technology Advisory Committee (OHTAC); Ontario Ministry of Health
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: Canada
Province: Ontario
Pubmed ID: 34055110
MeSH Terms
  • Heart Failure
  • Natriuretic Peptide, Brain
  • Biomarkers
  • Heart Diseases
  • Diagnosis
  • Natriuretic Peptides
  • Predictive Value of Tests
  • Natriuretic Peptides
  • heart failure
  • budget impact
  • cost-effectiveness
  • health technology assessment
Organisation Name: Ontario Health
Contact Address: 130 Bloor Street West, 10th Floor
Contact Name: Nancy Sikich
Contact Email:
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This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.